Drug Aging
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Apomorphine, a short-acting dopamine D1 and D2 receptor agonist, was the first dopamine receptor agonist used to treat Parkinson's disease. Subcutaneous apomorphine is currently used for the management of sudden, unexpected and refractory levodopa-induced 'off' states in fluctuating Parkinson's disease either as intermittent rescue injections or continuous infusions. Other indications include the challenge test for determining the dopaminergic responsiveness and finding the appropriate dose of the drug in intermittent subcutaneous administration. ⋯ Based on the results of these studies it is recommended that subcutaneous apomorphine either as intermittent injections or continuous infusions should be offered to any suitable Parkinson's disease patient who has difficulties in his/her management with conventional therapy. Low-dose levodopa therapy in combination with waking-day hours subcutaneous apomorphine infusion would probably be the most efficient treatment. Continuous subcutaneous apomorphine infusions should be evaluated before more invasive measures or neurosurgical interventions are contemplated.
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The number of elderly patients presenting for anaesthesia and surgery has increased exponentially in recent years. Regional anaesthesia is frequently used in elderly patients undergoing surgery. Although the type of anaesthesia (general versus regional anaesthesia) has no substantial effect on perioperative morbidity and mortality in any age group; it intuitively makes sense that elderly patients would benefit from regional anaesthesia because they remain minimally sedated throughout the procedures and awaken with excellent postoperative pain control. ⋯ Epinephrine also can prolong the duration of peripheral nerve blocks. However, caution must be exercised as epinephrine has the potential for causing ischaemic neurotoxicity in peripheral nerves. Regional anaesthesia appears to be safe and beneficial in elderly patients; however, every anaesthetic administered must be assessed on a case-by-case basis and particular consideration should be given to the health status of the patient, the operation being performed and the expertise of the anaesthesiologist.
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Streptococcus pneumoniae has been recognised as a major cause of pneumonia since the time of Sir William Osler. Drug-resistant S. pneumoniae (DRSP), which have gradually become resistant to penicillins as well as more recently developed macrolides and fluoroquinolones, have emerged as a consequence of indiscriminate use of antibacterials coupled with the ability of the pneumococcus to adapt to a changing antibacterial milieu. Pneumococci use cell wall choline components to bind platelet-activating factor receptors, colonise mucosal surfaces and evade innate immune defenses. ⋯ Treatment guidelines and recent studies suggest that combination therapy with a beta-lactam and macrolide may be associated with a better outcome in hospitalised patients, and overuse of fluoroquinolones as a single agent may promote quinolone resistance. The ketolides represent a new class of macrolide-like antibacterials that are highly effective in vitro against macrolide- and azalide-resistant pneumococci. Pneumococcal vaccination with the currently available polysaccharide vaccine is thought to confer some preventive benefit (preventing invasive pneumococcal disease), but more effective vaccines, such as nonconjugate protein vaccines, need to be developed that provide broad protection against pneumococcal infection.
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In response to concerns about, and issues pertaining to, medication use practices in residential aged-care facilities (RACFs), the Australian Pharmaceutical Advisory Council (APAC) established a working party on quality use of medicines (QUM) in nursing homes and hostels. The APAC is a representative ministerial advisory forum bringing together key stakeholders from the medical, nursing and pharmacy professions, as well as pharmaceutical industry, consumer and government sectors. The working party developed the integrated best practice model for medication management in RACFs. ⋯ This project has been groundbreaking in its impact on Australian aged-care practice. A major outcome has been significantly improved communication and collaboration between industry organisations, academic disciplines, professional bodies and educators involved in the RACFs.
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Neurodegenerative diseases are increasingly common in elderly patients, who present a particular anaesthetic challenge. The majority of people over the age of 70 years have some degree of cerebral atrophy. The pathogenesis of neurodegenerative diseases is due to alterations in the transport, degradation and aggregation of proteins. ⋯ This is particularly relevant to the timing of levodopa in Parkinson's disease, as missed treatment can be detrimental. Regional anaesthesia may, however, have significant advantages in patients with Parkinson's disease, who can continue to take oral levodopa preoperatively, during surgery, if required, and early in the postoperative period. Anti-emetic drugs such as phenothiazines, butyrophenones and metoclopramide should be used carefully in the postoperative period in these patients as their antidopaminergic effects may induce or exacerbate parkinsonian effects.